Macclesfield District General Hospital

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

At our last assessment we rated this key question good. At this assessment the rating has changed to requires improvement.

This meant the service management and leadership was inconsistent. Leaders and the culture they created did not always support the delivery of high-quality, person-centred care.

The service was in breach of regulation 17 for governance.

There were significant governance shortfalls, including poor version control of documentation, outdated policies, and risks not recorded on the risk register. Leaders lacked consistent oversight of operational risks, and systems for managing quality and safety were ineffective. Equality impact assessments were missing from key policies, and compliance with mandatory training, audits, appraisals, complaint responses and duty of candour was low. However, the trust had a clear vision and values, promoted freedom to speak up, and supported diversity through staff networks.

We have not awarded this service a score for Well-led.

Find out about when we will not publish a key question score and what we look at when we assess Well-led.

We scored the service as 3. The evidence showed a good standard. The trust had a shared vision, strategy and culture. This was based on transparency, equity, equality and human rights, diversity and inclusion, engagement, and understanding challenges and the needs of people and their communities.

There was a trust wide strategy and vision. We saw the trust’s visions and values on display around the hospital, visible to staff and visitors.

The trust’s strategy for 2022-2026 included plans on reducing health inequalities, creating a sustainable workforce and a clinical strategy.

The medical care division did not have its own strategy; however, leaders could give examples of how improvement programmes in the service contributed and linked into the overall trust strategy.

We scored the service as 2. The evidence showed some shortfalls. Not all leaders understood the context in which the service delivered care, treatment and support and lacked oversight of risks.

Leaders did not have a good understanding of the risks within the service or the actions being taken to mitigate these. There appeared to be a disconnect between the services, leaders were unaware of what was happening in corporate, governance and research departments when it related to their own service.

Leaders did not demonstrate consistent insight into the operational risks within frontline services. Systems to identify and manage risks were not consistently used effectively. There were shortfalls in governance which impacted on how leaders maintained oversight of the quality and safety of services.

Staff said that the matrons and senior leaders were visible on the wards, and they felt supported.

We scored the service as 3. The evidence showed a good standard. The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The trust had a freedom to speak up (FTSU) policy which provided staff with details of what they could speak up about, who to speak to and what the process would be if they did. The policy outlined the roles and responsibilities of the FTSU ambassadors and guardian.

Most staff we spoke with told us they were aware of the FTSU process, who the guardian was for the trust and who the ambassadors were in the division.

We saw posters with the freedom to speak up guardian and how to contact them. The trust did not have a full-time freedom to speak up guardian, it was a second role for a member of the governance team.

We scored the service as 3. The evidence showed a good standard. The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

The trust had 3 staff networks, cultural diversity, disabled and carers and an LGBT+ network.

We spoke with nurses who had been on the international recruitment programme; they said that they felt valued and welcomed.

The results of the 2024 NHS Staff Survey were generally close to the national average for staff from all other ethnic groups at the trust. The trust did show a slightly better experience in providing equal opportunities for career progression for other ethnic staff (53%) when compared to the national average (50%). This saw a positive increase by 9% compared to the previous year.

Outcomes for all other ethnic groups have shown improvement in comparison to the previous year’s results. We did not have a breakdown specifically for medical care.

We scored the service as 1. The evidence showed significant shortfalls. The service did not have clear responsibilities, roles, systems of accountability and good governance. They did not act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

A review of ward documentation revealed significant inconsistencies in record-keeping and version control across multiple areas. Several versions of key documents such as care plans and risk assessments were found, dating back to various years. For instance, on one ward, reasonable adjustment assessments included versions from both 2013 and 2018, indicating poor version control of documentation. We also found that some patient information leaflets were outdated and no longer in line with national guidance.

The service had an escalation policy outlining the processes to be used when the hospital reached full capacity. We received 2 versions of this policy, both the same document however showing different review dates, with one version past its review date.

Not all documentation included details of where they had come from. We observed daily checks for nutrition and hydration did not have the trust name on, which made it difficult to determine whether the information originated from the trust, a care home, or another provider.

The quality of care was observed to be heavily reliant on the leadership of individual ward managers. While all managers were actively engaged in driving improvements, this approach resulted in variability between wards. Such dependence posed a risk to continuity and consistency of care, particularly during periods of prolonged absence of ward managers.

Policies were not always up to date with the services systems. The policy for monitoring deteriorating patients was specific to an old electronic system and remained in use after the new system had been introduced, despite stating that the system would automatically advise on escalation plans, which was not the case for the new system. Leaders told us that this change in responsibility had been communicated with the staff however this was still a risk that deteriorating patients may not be escalated appropriately. This discrepancy between policy and practice was not recorded on the risk register, despite its potential impact on patient safety and staff accountability. Following our inspection feedback the service developed and implemented an updated policy in line with the system change.

There were shortfalls in governance which impacted on how leaders maintained oversight of the quality and safety of services. Leaders told us what they considered the main risks in the service were, however, some of these were not included on the service’s risk register. We were told of several risks that were also not on the risk register such as lack of nasogastric (NG) tube trained staff within the service to manage patients with NG tubes. Poor compliance with MCA documentation had been identified in October of 2024, with no follow up action to address this.

The trust did not always consider how their decisions and policies affected people based on their protected and non-protected characteristics. Not all policies had equality impact assessments such as the Rapid Tranquilisation Policy and the Parkinson's Medicine Administration Policy that stated an impact assessment was not applicable. This meant that the impact of these policies on people had not been considered, and some people could be disadvantaged and face inequalities in their care and treatment.

The service performed poorly in managing complaints and meeting duty of candour requirements.

The trust was behind for mandatory training compliance, appraisal compliance, national and local audits and outcomes. Leaders told us they had a “recovery programme” for training and appraisal compliance, however it was unclear how this programme specifically targeted the underlying cause of this low compliance.

We scored the service as 3. The evidence showed a good standard. The service understood their duty to collaborate and work in partnership, so services work seamlessly for people. They share information and learning with partners and collaborate for improvement.

We received limited feedback from partners for the service. However, the feedback we did receive for medical care was positive stating that the trust engaged in respectful and compassionate joint working, with shared care planning and multi-agency engagement supporting continuity and quality of care.

Partners said that the trust recognised the needs of the local community, including a growing elderly population, and worked with them to develop community-based care models that promoted independence and to reduce hospital admissions

We scored the service as 2. The evidence showed some shortfalls. The service did not always actively contribute to safe, effective practice and research.

The service did not always participate in national audits relevant to the service or learned from them. However, the trust provided evidence of internal quality improvement projects such as the 90-day pressure ulcer challenge and partner working to improve clinical pathways.

Some wards had boards with different handles and switches on to provide sensory stimulation for people with dementia, particularly those experiencing restlessness or agitation.

The trust was selected to present its Professional Nurse Advocate implementation at the National PNA Conference in June 2025 as an example of good practice.